21 May 2010

The complaint was "Visual hallucinations," and the patient was not exactly the sort of individual you would expect to be hallucinating. He was a middle-aged, affluent corporate executive, a sharp and high-functioning individual with no history of either substance abuse or mental illness. He was, therefore, rather perturbed by the little red and green elves he kept seeing all over the place. He knew they weren't real, but they just wouldn't go away. (We attributed the fact that they were red & green to the fact that this case occurred shortly after Christmas.)

My partner, "Bill," was a superb physician, but I would never let him take care of me in a million years. Not because his skills aren't good: they're excellent. He's one of the best doctors I have ever had the honor of working with. But Bill is what is known in the business as a "black cloud," or, less politely, a "shit magnet." Somehow he always manages to get the most awful, obscure, or just plain bizarre cases, and when he works, the crazies always come out in force. In fact, it was Bill who signed out this gem to me. So when he came to me with this case, perplexed and looking for advice, I was not particularly surprised. It seemed par for the course for him. The work-up in these cases is pretty straightforward and almost always unsatisfying: rule out medical causes and consult psychiatry. So Bill orders a slew of labs and a CT scan of the brain.

This is where it gets weird. Um, weirder. For some reason, Bill ordered a Troponin, which is a blood test marker of heart damage. I wouldn't have ordered it -- there's no logical connection between the heart and odd psychiatric symptoms. I would have probably confined my lab tests to electrolytes, blood sugar, a drug screen, that sort of thing. But Bill, conditioned by the strange stuff he sees, casts his net a bit wider. And the troponin came back strongly positive.

Which was completely unexpected. We had not even done an ECG. But when he saw the troponin, Bill immediately ordered one, and saw something like this:

Which was even more unexpected. The following amusing conversation with a cardiologist ensued:

"So I have a guy here having a heart attack with a positive ECG and troponin."

"Great. I'll be right in. Is he still having chest pain?"

"Well, that's the funny thing. He's never had any pain."

"Interesting. What was his presenting symptom?"

"Visual hallucinations. Elves. Christmas elves, we think."

"Bullshit. You are kidding me, right?"

But we faxed him the ECG, which was really quite convincing, and the cardiologist came in reluctantly, and somewhat dubiously took the patient to the cath lab. Sure enough, the patient had a high-grade obstruction of his LAD, and upon opening it, that patient's ECG returned to normal. The next morning on rounds, the patient thanked the cardiologist for saving his life, and ventured that he didn't want to seem ungrateful, but the elves were still bothering him, and could he please do something about that? Psychiatry saw the patient and concluded that he wasn't crazy. So the neurologist was called in and noticed an odd motor tic every time the patient looked at the elves, who were always sitting to his left. The neurologist speculated that the hallucinations might be a form of a partial complex seizure, so he started the patient on an IV drip of dilantin, an anti-seizure medicine.

And the Elves went away.

So there you have it: Acute Anterior Myocardial Infarction presenting with Partial Complex Seizures manifested as hallucinations of Christmas Elves.

And that, ladies and gentlemen, is the weirdest damn thing I have ever seen.Originally Published 17 July 2007

well, as far as the last bit goes...anti-seizure drugs are pretty well known to have been proven effective and are frequently prescribed as anti-psychotics....so the fact that the anti-seizure drug got rid of the elves, doesn't rule out some sort of mental illness problem that could be more long-term. they really ought to still send him through psychiatry as well.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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